Hello there, fellow medical billers. We have all been here before. There are tons of claims piling up on your desk, deadlines are looming, and your manager is pressuring you to get things done quickly. It’s no secret that the ultimate aim of the healthcare remuneration cycle management is to maximize payment. But there’s a massive difference between optimizing a claim and crossing the line into upcoding.
Upcoding happens when a claim is submitted with a higher-paying code than the clinical documentation actually supports. Sometimes it’s a simple keystroke error; other times, it’s intentional upcoding of Medicare billing fraud. As the last line of defense before a claim is submitted to CMS, if we miss the warning signs, the practice risks audits, massive payment recoupments, and serious legal trouble.

Here are five red flags of Medicare upcoding you need to keep on your radar.

The “Always Level 5” Evaluation and Management (E/M) Codes

The E/M codes are the most used codes in any practice’s coding needs; however, these are also the most vulnerable codes to upcoding. An upcoding audit would pose a big risk for your practice when providers always bill level 4 and level 5 E/M codes (99214/99215) for follow-ups.

A Level 5 visit requires high complexity in medical decision-making or an extended period of time spent with the patient. If the doctor’s notes say, “Patient stable, renew prescription, return in 6 months,” the documentation likely does not support a high-level code. Watch for providers whose billing curves heavily skew toward the highest codes compared to their peers.

Abuse of Modifiers 25 and 59

Modifiers are essential for telling the whole story of a patient encounter, but Medicare heavily scrutinizes them.

• Modifier 25 is used for a significant, separately identifiable E/M service by the same physician on the same day of a procedure.
• Modifier 59 indicates a distinct procedural service.

The red flag waves when these modifiers are slapped on almost every claim just to bypass National Correct Coding Initiative (NCCI) edits. If the documentation doesn’t clearly show that the services were distinct, separate, and medically necessary, using these modifiers to artificially inflate the payout is a massive compliance risk.

“Copy and Paste” EHR Cloning

Electronic Health Records (EHRs) are supposed to make life easier, but the copy-forward feature is a major culprit in accidental upcoding. If you review a chart and the patient’s history, review of systems, and physical exam look identical to their visit from three months ago—down to the typos—you have a cloning problem.
When doctors copy and paste notes, it artificially inflates the volume of documentation, which can trick the coder into selecting a higher-level code. Medicare auditors are trained to spot cloned notes; every claim must stand on its own unique, date-specific documentation.

Diagnosis Severity Inflation

Medicare Advantage uses HCC (Hierarchical Condition Category) coding, where the illness conditions of patients determine the risk codes. The more ill the patient is, the more money the health plan will get as restitution from Medicare.
One such big warning sign is when the diagnostic codes get significantly worse without supporting evidence from the clinical documentation. For example, where severe malnutrition is coded even though the patient has only skipped a meal or where an area problem has been coded systemically without any laboratory findings. If the clinical scenario does not support the severity of ICD-10 codes, it is upcoding.

Routine Unbundling of Bundled Procedures

Unbundling can be considered upcoding’s secretive brother. The Medicare program expects some procedures that are usually done together to be submitted for billing under just one bundled code. What should raise an eyebrow is when more than one component code is billed instead.

A classic example is billing for several individual blood tests when a comprehensive metabolic panel code exists. Because the individual codes combined usually pay more than the bundled code, this is a clear tactic to improperly maximize reimbursement.

What to Do When You Spot the Flags

As a biller, there is a moral and legal responsibility to see that claims correctly represent services provided. In case you notice any of the following trends:

• Query the Provider: Do not jump to conclusions immediately thinking it’s an intention to cheat. Perhaps the physician needs some education on documentation. Keep a paper trail of your concerns.
• Protect Yourself: If you are pressured by management to submit claims you know are false, you might be stepping into whistleblower territory. In cases of systemic abuse, consulting a Medicare fraud lawyer can help you understand your rights and protections under the False Claims Act.

Being in the medical billing field can already be difficult. And with the constant fear of CMS audits on the horizon, vigilance is essential for you to protect not only yourself but your patients and even your practice.